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EHD LOG NUMBER <br /> U SAN JOAQUIN COUNTY <br /> N01 4 ENVIRONMENTAL HEALTH DEPARTMENT <br /> ��� 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 RO <br /> ENVIRONMENT HEALTH Telephone: (209)468-3420 Fax: (209)464-0138 Web: wivw.sjgov.org/ehd <br /> PERMIT/SERVICES <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT:.- rjNN BUSINESSlAGENCY: (--6W,9Uf74>� <br /> ADDRESS: 1-71,37 21>7 <br /> PHONE(1};.55� �7j ss15�7 PHONE(2): o FACSIMILE; <br /> TENTATIVE*APPOINTMENT DATE: ( Time: <br /> (Please allow 10 business days from date)" <br /> appli atlon submittal-"Tentative only-must be confirmed) <br /> I CHECK SOX TO EXPEDITERVEST�$92.xOD F E(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 B INE S DAYS <br /> SIGNATURE OF APPLICANT A4M DATE I f <br /> UNIT DISTRIBUTION ❑ Unit ❑ UnI#2 eUnit Unite ❑ Unit 5 ❑ Unit fi ❑ Other(election ic/Istslmaps) <br /> FILE KESS EHD USE ONLY <br /> Street# Street Name City <br /> 1. 2 1 <br /> 2. <br /> 3. — <br /> 4. <br />�. 6 <br /> 7. <br /> 8. <br /> 9. <br /> 10. <br /> r <br /> Specific Date Range of information Requested: From � ' J'k`I17� ` to <br /> x- <br /> j; ENVIRONMENTAL HEALTH DEPARTMENT FILES 5: � <br /> v_ <br /> )<UNDERGROUND TANK(LIST)CLEANUP SITE(LOP) ■HOUSING ABATEMENT 0 SOLID WASTE F <br /> ❑OTHER CLEANUP SITE(NON-LOP):' . 11 FOOD FACILITY El WASTE TIRE <br /> UNDERGROUND TANK(MONITORING IREMOVAL) ❑ DOG KENNEL ❑DAIRY <br /> ❑HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MoTELIHOTEL ❑PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑TATTOO/BODY PIERCING ❑POOLISPA ❑ LAND USE APPLICATION SITES <br /> I ❑MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPECIFY) <br /> I. <br /> fWELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW - MONDAY-FRIDAY 8:00 AM-5:00PM - EXCLUDING HOLIDAYS. <br /> 1. List up to ten addresses'in the space above. Select the type(s)of files from the list above by checking the <br /> appropriate box(es). At least one file type MUST be selected. Fax to(2091464-0138 or mail-to..the°address___ <br /> indicated above. Address ranges will not be accepted–for additional assistance with file addresses_,contact <br /> the EHD.Applications received after 3:00 pm will be processed the next business day. <br /> 2. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed <br /> approximately ten (10) days after receipt of application. The files will be held for a maximum of five business <br /> days for review. Appointments Should be scheduled accordingly. <br />` 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new <br /> application may be submitted when the file is available. <br /> I <br /> 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the <br />{: applicant. Future file reviews by the same applicant may require a$93.00 deposit prior to review. <br /> EHo 48-02.006 <br /> v�a0s <br /> 1 � <br />